Mental Health Foundation - RESEARCH REPORT · and enduring mental health problems stress can precipitate symptoms and potentially result in relapse. For example, stressful life events

1RESEARCH REPORT

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Citation: Mental Health Foundation (May 2018). Stress: Are we coping? London: Mental Health Foundation

Produced by: Chiara Samele, Harry Lees-Manning, Victoria Zamperoni, Isabella Goldie, Lucy Thorpe, Emily Wooster, Toni Giugliano, Chris O’Sullivan, Antonis Kousoulis, Josefien Breedvelt, Mark Rowland & Richard Grange

Good mental health is fundamental to thriving in life. It is the essence of who we are and how we experience the world. Yet, compared to physical health, so little is commonly known about mental ill health and how to

prevent it. That must change.

The Mental Health Foundation is the UK’s charity for everyone’s mental health. With prevention at the heart

of what we do, we aim to find and address the sources of mental health problems.

We must make the same progress for the health of our minds that we have achieved for the health of our bodies. And when we do, we will look back and think that this was

our time’s greatest contribution to human flourishing.

The Mental Health Foundation is a UK charity that relies on public donations and grant funding to deliver and

campaign for good mental health for all.

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Contents

What is stress?

How many people feel stressed?

How does stress affect us physically?

How does stress affect us psychologically?

What makes us stressed?

Distribution of stress across the population

How can stress be addressed and managed?

Conclusion and Recommendations

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WHAT IS STRESS?

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While we all know what it feels like to feel overwhelmed or unable to cope with the pressure we face, when it comes to research around stress, it can be surprisingly difficult to pin-point what exactly ‘stress’ is.

At the most basic level, stress is our body’s response to pressures from a situation or life event (called a ‘stressor’). What counts as a ‘stressor’ can vary hugely from person to person and differs according to our social and economic circumstances, the environment we live in, our genetic makeup and physiology. Some common features of stressors include experiencing something new or unexpected, something that threatens your competence/ego, and a feeling of little control over a situation.1

When we encounter a stressor, an important pathway in our body and brain, the hypothalamic-pituitary-adrenal (HPA) axis, is stimulated to produce stress hormones (cortisol and catecholamines) that trigger a ‘fight or flight’ response. Our immune system is also activated to prepare for possible injury.2 This process helps us to respond quickly to dangerous situations.

Sometimes, this stress response can be an appropriate, or even beneficial reaction. The resulting feeling of ‘pressure’ from the stress response can help us to push through situations that can be nerve-wracking or intense,

such as running a marathon, or giving a speech to a large crowd. We can quickly return to normal (called ‘homeostatic baseline’) without any negative effects on our health if our exposure to the stressor is short-lived.3 Many people are able to deal with a certain level of stress without any lasting adverse effects. This ability to resist and grow our resistance to stressors (sometimes called ‘resilience’) varies between individuals according to their genetics, experiences, and the environment in which they find themselves.

For many of us there are times when exposure to stressors become too frequent or too intense to deal with. If our stress response is activated repeatedly, or it persists over time without recovery periods, the physiological effects result in cumulative wear and tear on the body (or allostatic load) and can cause us to feel permanently in a state of ‘fight or flight’.4 Rather than helping us push through, this pressure can make us feel overwhelmed or unable to cope.

While stress is not a mental health problem in and of itself, experiencing overwhelming stress for a long period of time is often called chronic, or long-term stress, and it can impact on both physical and mental health.

This overwhelmed feeling is what we refer to as ‘stress’ throughout this report.

Stress is our body’s response to pressures from a situation or life event.

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Information on how many people in the UK population as a whole are affected by stress is very limited. However, our new survey found that over the past year, almost three quarters (74%) of people have at some point felt so stressed that they felt overwhelmed or unable to cope. The survey, commissioned by the Mental Health Foundation and undertaken by YouGov, polled 4,169 adults in the UK in 2018.i This stress study had a sample size of 4,619 respondents. Another recent poll concurs with this finding with 82% of people feeling stressed at least some time during a typical week, and eight percent that felt stressed all the time.5

One area of stress that is frequently researched is self-reported work-related stress. The number of people experiencing work-related stress, as well as mental health problems such as anxiety, or depression in the UK has remained broadly stable since 2006/7 but nevertheless persistent. Around half a million people are experiencing work-related stress in the UK.6 The literature on stress at work suggests several models of stress in the workplace. One model posits that a lack of balance

between effort and reward can cause stress. Another suggests a lack of balance between demands made by a job, and the control given to manage tasks, may contribute to stress.7

One recent poll found that women report more stress than men (89% vs. 76%)8 This may be the case both in general, and in the workplace.9 Certain ethnic groups also experience more work-related stress (particularly African-Caribbean women), which has been linked to reported incidents of racism.10

As people become much older (70 years and over) they very often have to deal with long-term health problems or disability, the loss of friends and family and coming to terms with their own mortality, but interestingly they have been found to report less stress.11 One previous poll found that people aged 55 and over report the least amount of stress, with 29% reporting not being stressed at all.12 This can also be seen in our survey, where 30% of those aged 55 plus reported “never” feeling overwhelmed or unable to cope in the last year, compared to 7% of young adults (aged 18-24).

iAll figures, unless otherwise stated, are from YouGov Plc. Total sample size was 4,619 adults. Fieldwork was undertaken between March 29th and April 20th, 2018. The survey was carried out online. Figures have been weighted and are representative of all UK adults (aged 18+).

74% of people have at some point felt so

stressed that they felt overwhelmed or

unable to cope.

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The impact of long-term stress varies enormously from person to person and can have far reaching consequences if left unmanaged. People may notice that their sleep and memory are affected, their eating habits change, and/or they feel less inclined to exercise. Some people may smoke, consume more alcohol or take drugs to relieve stress. In our survey, of adults who reported experiencing stress, 46% reported that they ate too much, or ate unhealthily due to stress. 29% reported that they started drinking or increased their drinking, and 16% reported that they started smoking or increased their smoking.

Long-term stress, and the associated stress response, can also impact on our physical health in other ways. In terms of specific physical health problems, stress can affect our gastrointestinal system as our brain activity and gut are closely inter-connected. Irritable bowel syndrome, for instance has been associated with psychosocial stressors (e.g. work-related stress, money problems, lack of social support).13 Stomach ulcers are a classic example of the impact of stress and gastrointestinal functioning.

Significant attention has also been given to the link between stress and cardiovascular disease. For example, the INTERHEART study, conducted across 52 countries, found a strong relationship between psychosocial stress and myocardial infarction (a heart attack), comparable to the effects of smoking and hypertension.14 Stressful living circumstances or working conditions

have been linked to high blood pressure, the development of diabetes and ischemic heart diseases such as angina.15

Chronic stress can also affect the immune system, with prolonged or frequent activation of the stress response thought to play a role in disrupting healthy immune responses. This may be especially problematic for older people as immune function also declines with age, making it harder to fight off viral infections.16 It may also explain why one of the first signs of chronic stress can be experiencing frequent short illnesses. The effects of chronic stress on the immune system may also be linked to inflammation in the body, which recent research suggests may be a risk factor for depression.17, 18

Poorer physical health and shorter life expectancy have been found in people with lower education and lower occupational status compared to those with higher occupational status.19 The Whitehall studies, a series of research studies looking at the relationship between health and job grade in civil servants, found that the lower a person’s job status the more likely they were to experience ischaemic heart disease. They also reported having more stressful life events in the previous year and money problems, compared to people in higher occupational grades.20 In the same study, more women reported having angina (ischemic heart disease), indicating a difference in the types of physical illness experienced by each gender group.

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There is a growing strong body of research which unsurprisingly suggests that chronic stress, and exposure to stressors, can have a negative impact on mental health.

The experience of stressful life events has been found to be associated with depressive symptoms and the onset of major depression,21, 22 as well as suicide, suicidal thoughts23 and self-harm.24

This was also the case in our survey, where we found that over half of adults (51%) who felt stressed reported feeling depressed, and 61% reported feeling anxious. Of the adults in our survey who said they had felt stress at some point in their lives, 16% said they had self-harmed, and 32% said they had suicidal thoughts and feelings.

Stress may also play a role in exacerbating existing mental health problems. For people living with severe and enduring mental health problems stress can precipitate symptoms and potentially result in relapse. For example, stressful life events have been found to be associated with acute relapse of schizophrenia.25

There may be many reasons for this link between stress and mental health. Some researchers believe that stress can interact with existing biological, psychological, or social risk factors to produce a cumulative effect that can contribute to the onset of mental health problems.26, 27 This suggests that some people may be more susceptible to the effects of chronic stress and stressful life events than others, either as a result of encountering more stressors, or because of the presence of other pre-existing risk factors.

This may particularly be the case for those living in poverty, from minority communities, people who are socially isolated, or with pre-existing or ongoing health problems or disabilities.

For example, the psychological and physical harm stress can have on minority communities, such as those who are LGBT (lesbian, gay, bisexual and transgender), tends to be greater because of the impact of stigma and discrimination.28 This may also be the case for individuals from minority ethnic groups, with research suggesting that there are ethnic and gender

Over half of adults (51%) who felt stressed reported feeling depressed,

and 61% reported feeling anxious.

Of the adults who said they had felt stress at some point in their lives, 16%

said they had self-harmed, and 32% said they had suicidal thoughts and feelings.

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differences in the link between stress and depression, potentially perpetuating health disparities.29

Financial stress because of personal debt is another well recognised risk that can lead to common mental health problems.30 For people living in poverty, stress has been found to contribute to the relationship between lower socio-economic status and poorer mental health outcomes.31, 32 High levels of debt and financial insecurity increases the likelihood of living in an unstable or poor quality housing situation, experiencing job stress, having more adverse life events and less social support, all of which can further erode our mental health.33

There is a robust body of research on the impact of adverse childhood experiences and trauma on mental health. We cannot do justice to this wealth of evidence within the scope of this report, but it should be acknowledged that these events can not only be extreme stressors at the time they are experienced, but they can also increase the impact of and susceptibility to other sources of stress in future.

Work-related stress can also contribute to common mental health problems such as depression.34 Job strain and having few decision-making responsibilities mostly explain this relationship. A more recent review found that an imbalance in job design, job insecurity

and experiencing a lack of respect or being undervalued in the workplace could contribute to the development of depression or anxiety.35

Work-related stress in 2016/17 accounted for an average of 23.9 work days lost for every person affected.36 It has now been estimated that around 15% of people at work have a mental health condition;37 and 300,000 people with a long-term mental health problem in the UK lose their jobs each year.38 For these reasons, tackling stress at work should be a major priority, as should be creating a supportive workplace culture that promotes mental health and enables people to seek help safely, without risking adverse consequences.39

Stress may also impact on mental health more indirectly, by affecting how individuals interact with others, including partners, and family members, potentially placing strain on these relationships.40 In our survey, 37% of adults who reported feeling stressed reported feeling lonely because of stress. Reported loneliness declined with age, with figures ranging from 53% of 18-24 year olds to 25% of those aged 55 and over. A 2010 report by Mental Health Foundation further elaborates on the relationship between loneliness and stress, with some research suggesting that loneliness may be both a source of stress and can increase perceptions of stress.41

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WHAT MAKES US STRESSED?

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There are many things that can act as stressors. The death of a loved one, divorce/separation, losing a job and unexpected money problems are among the top ten causes of stress according to one recent survey.42 But not all stressful life events are negative; even positive life changes, such as getting married, having a baby or retirement are by no means stress-free.43

Long-term Health Conditions

Long-term health conditions (either one’s own, or those of close family and friends) was the top stressor reported in our survey, with 36% of all adults who reported stress in the previous year citing it as a stressor. While long-term health conditions can be stressful for a variety of physical and psychological reasons, stress may be exacerbated by those individuals feeling unsupported by services, in particular with regards to their mental health and wellbeing. A recent Mental Health Foundation report, which interviewed cancer patients in Scotland, found that 49% felt they received no support or advice from health services about managing their mental health, and over half felt that better communication from service providers would have improved their wellbeing during and after treatment.44

Work

We spend a huge amount of time at work. We know that good work can be very beneficial to mental health, but it isn’t surprising that work has been identified as a major stressor for many people. One recent poll found that more than a third of people (38%) reported

being stressed about work, with many reporting taking work calls and checking emails outside of working hours (59% and 55% respectively).45

Balancing home and work can be difficult at the best of times, particularly for people working in demanding or pressured jobs. A 2017 Unison survey found 92% of people felt they had been under too much pressure at work at some point, and 67% considered excessive work demands as the source of their stress at work.46 Much of this was attributed to working long hours (e.g. 12 hours a day all week), staff cuts and having to take on more work to compensate for this, difficulties with their line manager and conflicting work and home demands. What is more, UK workers are working an average of 7.7 hours a week of unpaid overtime.47

Work-related stress in NHS staff has reached alarming levels. Recent figures show that in 2016, 15 million working days were lost because of stress, anxiety or depression.48 Frontline healthcare staff in the NHS, particularly those supporting clinical staff (5.5%), ambulance staff (5.4%) and nurses (4.5%) have the highest absence rates.49 Overall, stress, depression and anxiety are the fourth most common reasons for absence; affecting female staff (7.8%) slightly more than male staff (7.6%).50

Furthermore, stress-related absence is increasing for other public sector workers (including those working in local government), with figures from a 2016 survey showing an increase of almost two thirds reporting mental health problems compared to 2015. This is twice that reported by employees in the private sector.51

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Money

Financial concerns are another major stressor. A previous poll found that for many the concern is about pay or salary prospects (72%) and paying household bills (60%).52 Not having enough money to meet basic needs was one of the top three listed sources of stress reported by adults in our survey, with 22% of adults who reported stress in the previous year citing it as a source of stress.

Recent figures have shown that although the number of employed people has increased, earnings have not risen much since before the 2008 recession; subsequently in-work poverty has increased and living standards have been falling.53 Overall, 14 million people live in poverty in the UK, with rates recently beginning to rise.54 Struggling to make ends meet can be a stressor for many, especially for those living on low incomes or below the poverty line and can leave individuals susceptible to physical and mental health problems.55

The cost of consumer loans/credit has increased by 10%, far more than rises in income. There is also evidence that people are using more credit to buy goods; which could result in unmanageable debts if they are unable to make repayments on time.56 Indeed, our survey found that of adults who reported feeling stressed in the last year, more than one in five (22%) reported feeling stressed due to debt.

Our survey also found that 29% of non-working adults, or adults working in skilled, semi-skilled, or unskilled occupationsii reported not having enough money to meet basic needs as a source of stress. This reduced to 17% for adults working in supervisory, managerial, administrative or professional occupations.iii This group were also more likely to report the long-term health conditions of themselves, close friends, or family as a stressor (41%) compared to adults in supervisory, managerial, administrative or professional occupation.

Technology and social media

While technology and social media can have positive effects for many, for some, it can also have negative effects. Whilst beyond the scope of the current report, it is clear that while technology and social media can serve as a protective factor, in some ways it may also contribute to stress.

There has been much coverage about the impact of technology and social media on stress, a phenomenon now sometimes termed ‘digital stress’. Ofcom’s survey of media and digital participation conducted in 2016 identified interesting demographic trends in the use of technology, finding a steep rise in the number of people over 65 who use smart phones and access social media.57 This suggests that an increasing number of adults of all ages

ii Based on C2DE social gradeiii Based on ABC1 social grade

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are accessing social media and thus susceptible to the effects of social media on stress.

The immediacy and ubiquity of social media means that pressure to always be available online can have negative impacts. In our survey, of those adults online who reported feeling high levels of stress, more than one in ten (12%) said that feeling like they need to respond instantly to messages (e.g. replying to WhatsApp messages, messages on social media etc.) was a stressor.

Smartphones have become central to navigating daily life. People are more likely to access the internet via their smartphone, using it for a variety of things. Becoming over-dependant on a smartphone can be a risk, and some people feel anxious if their phone is not close by, and even more so if it’s lost. This is most marked for people aged 18-34.58

For young people the scrutiny of social media can become overwhelming. The constant pressure to keep up with their peers for fear of being left out or excluded can be a powerful source of stress. For example, our survey found

that nearly half (49%) of 18-24 year olds who have experienced high levels of stress, felt that comparing themselves to others was a source of stress, which was higher than in any of the older age groups.

Wider issues that can act as stressors

Events outside the sphere of our immediate personal lives can contribute to feelings of stress. Societal factors ranging from the daily news to commuting delays can also take their toll.59 Natural disasters, as well as other traumatic events can induce extreme stress responses, including post-traumatic stress disorder.60

In the US, a recent survey of stress found that almost two-thirds of adults were very or significantly stressed about the future of the nation (63%), followed swiftly by concerns about money (62%) and work (61%).61 In our survey, nearly one in five (19%) adults in the United Kingdom who use the internet, and who reported high levels of stress, said their feelings about current affairs were a source of stress.

DISTRIBUTION

OF STRESS ACROSS THE POPULATION

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DISTRIBUTION

OF STRESS ACROSS THE POPULATION

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The distribution of stressors has been found to vary between groups. One review found that traumatic and stressful life events are more frequently reported in people living in deprivation, from minority ethnic communities, and in younger age groups (18 years and above).62

One recent poll found that women report similar stressors to men; however, they prioritise them slightly differently. The leading stressors in women include personal finance (43%), health of family and friends (41%) and personal health (40%), whereas for men it is work pressures (41%), personal health (32%) and personal finance (30%).63 These differences may in part be explained by traditional gender roles and the way men and women are socialised.64

Rates of emotional problems for young women are higher than those for young men, and have been found to be increasing, with national data finding higher rates in 2014 compared to 2009 data.65 Some researchers have theorised that this may be due, in part, to an increase in concerns around body image and how this impacts on self-esteem in young women.66, 67 Our survey found

that 36% of women who felt high levels of stress related this to their comfort with their appearance and body image, compared to 23% of men, highlighting a critical need for preventative action.

For adults aged over 55, personal long-term health conditions and/or those of close family and friends can be a significant stressor. Our survey found that 44% of adults in this group reported this as a source of stress in the last year.

For young people, our survey found housing worries (paying rent, affording to buy a house) to be key stressors, with more than one in three adults (32%) aged 18-24 reporting this as a source of stress in the last year (compared to 22% of 45-54 year olds, and 7% of those aged 55+). They also reported higher stress related to the pressure to succeed, with 60% of 18-24 year olds, and 41% of 25-34 year olds reporting this as a stressor, compared to only 17% of 45-54 year olds, and 6% of those aged 55+.

For young people in higher education, exams are considered to be reasonably or very stressful (90.5%), so too has thinking about their career prospects (75.2%) and having enough money to get by (68.2%).68

For young people, our survey found housing

worries to be key stressors, with more than one in three

adults (32%) aged 18-24 reporting this as a source of

stress in the last year.

HOW CAN STRESS BE ADDRESSED AND MANAGED?

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HOW CAN STRESS BE ADDRESSED AND MANAGED?

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Realise when it is causing you a problem and identify the causes. You need to make the connection between feeling tired or ill with the pressures you are faced with. Do not ignore physical warnings such as tense muscles, over-tiredness, headaches or migraines. Sort the possible reasons for your stress into those with a practical solution, those that will get better anyway given time, and those you can’t do anything about. Take control by taking small steps towards the things you can improve.

Review your lifestyle. Are you taking on too much? Are there things you are doing which could be handed over to someone else? Can you do things in a more leisurely way? You may need to prioritise things you are trying to achieve and reorganise your life so that you are not trying to do everything at once.

Build supportive relationships and social networksFind close friends or family who can offer help and practical advice to support you to reduce your stress. Joining a club or enrolling on a course are good ways to expand your social networks and to encourage you to do something different. Equally activities like volunteering can change your perspective and helping others can have a beneficial impact on your mood.

Given the potential impacts of prolonged stress, learning ways of managing, reducing, and preventing stress can be important tools for mental and physical health and wellbeing.

There are actions that can be taken by individuals to do this, but as discussed

elsewhere in this report, often people are affected by stressors that are beyond their direct control (e.g. living in poverty, discrimination, with long-term health problems etc.) so we must also consider what can be done at a wider community and societal level to mitigate and reduce long-term stress.

TOP 10 INDIVIDUAL ACTIONS

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Eat Healthily. A healthy diet will reduce the risks of diet-related diseases. Also, there is a growing amount of evidence showing how food affects our mood. Feelings of wellbeing can be protected by ensuring that our diet provides adequate amounts of nutrients such as essential vitamins and minerals, as well as water.

Be aware of your smoking, drinking and caffeine intake. Even though they may seem to reduce tension, this is misleading as they make problems worse. Alcohol and caffeine can increase feelings of anxiety.

Exercise. Physical exercise can be an excellent initial approach to managing the effects of stress. Even going out to get some fresh air and taking some light physical exercise, like walking to the shops, can help when you feel stressed. You do not need to do much, walking 15-20 minutes, three times a week is a good way to feel better.69

Take time out. Take time to relax. Saying ‘I just can’t take time off’ is no use if you are forced to take time off later through ill health. Striking a balance between responsibility to others and to yourself is vital in reducing stress levels.

Be mindful. Mindfulness meditation can be practiced anywhere at any time. Research has suggested that it can be helpful for managing and reducing the effect of stress, anxiety and other related problems such as insomnia, poor concentration and low moods, in some people.70 Our ‘Be Mindful’ website features a specially-developed online course in mindfulness, as well as details of local courses in your area: https://bemindful.co.uk/

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Get some restful sleep. Sleeping problems are common when you’re suffering from stress. Try to ensure you get enough rest. Writing down your to do list for the next day can be useful in helping you to prioritise but also to park these plans before bed.71 For more tips on getting a good night’s sleep read our guide ‘ How to….sleep better at: www.mentalhealth.org.uk/publications/how-sleep-better

Don’t be too hard on yourself. Try to keep things in perspective. Look for things in your life that are positive and write down things that make you feel grateful.

If you continue to feel overwhelmed by your stress seek professional help to show you how to reduce and manage the stress you are experiencing. Cognitive behavioural therapy (CBT) has been shown to be helpful in reducing stress by changing the way we think about stressful situations; this might include focusing on more positive elements of a situation and reassessing what their likely impact might be.72 Other psychosocial interventions include brief interpersonal counselling which gives people the opportunity to discuss recent stressful situations and develop coping strategies to address these.73

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Community and Societal Actions

The topic of stress is a broad one that covers many aspects of life. Despite the breadth of this topic and with some notable exceptions many stress-specific interventions are focussed on the individual, highlighting a need for further research and innovation in this area and in particular around those community and wider societal stress reduction measures. Given this, we have selected a couple of top-line examples of where stress can be addressed systematically.

Improving health and wellbeing of employees: There are numerous resources and guidelines to promote the mental health and wellbeing of employees and to manage/prevent work-related stress. The best of these have been reviewed systematically and include standards and practical tools for employers.74 Some of the key elements include creating good psychosocial conditions at work - balancing work demands, enabling a level of employee control/autonomy, creating a supportive work environment, managing relationships, ensuring role clarity, recognition and reward and organisational justice.

Organisational culture at work, linked to psychosocial conditions, is also important to focus on, which can be enhanced by offering effective

leadership and line management training and workplace interventions to reduce stress and improve mental health at work.75

Mental Health and wellbeing for everyone: There are various interventions for promoting mental health and wellbeing at national and community level. Although they may not be focused on reducing stress specifically, they do target many of the potential consequences, such as mental health issues, suicide, health inequalities and premature mortality and many of the determinants are the same. Recent Public Health England (PHE) guidance details the responsibilities of healthcare professionals and local authorities in this area.76 One element includes acting to reduce poverty and improve housing and employment opportunities. Others concern providing accessible information and resources (including signposting to relevant services).

At a community level (e.g. within a certain locality or geographic area) the PHE guidance encourages healthcare professionals to work jointly with local authorities to reduce mortality and health problems. Here importance is placed on forging links with local services, including community and voluntary organisations as a way of connecting with local health and wellbeing initiatives (e.g. walking and gardening, enhancing social connections, exercise classes).

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CONCLUSION AND RECOMMENDATIONS

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It is common to experience stress at some point in a typical week. Not everyone experiences chronic or long-term stress but for those that do its impact can be significant, negatively affecting both their mental and physical health. The reasons for becoming stressed vary greatly, but often relate to work, money, our personal health, the health of those close to us, and certain life events including the cumulative impact of adversity. It is also clear that some groups are more exposed to the risk of stress than others.

Fortunately, there is much we can do to manage, reduce and mitigate the effects

of stress. There are many approaches or strategies we can use to help us at an individual level. However, we can go further and seek change at a community, organisational and/or governmental level to tackle wider socio-economic and environmental stressors.

Further research into preventing stress at this wider level is needed and this is closely linked to factors that promote our overall mental health and wellbeing. At the Mental Health Foundation, we will continue our work in this area, and call on others to support us to systematically fill this gap, starting with a 7-point plan outlined below.

Health and social care professionals should assess and address the psychological and other stressors experienced by people living with long-term physical health conditions. It is well documented that the vast majority of people are not given psychological support for long-term physical health conditions, despite the fact that they are two to three times more likely to have mental health problem such as depression and anxiety. It is also well known that people have poorer outcomes for physical illness when under stress or experiencing comorbid anxiety and depression.77 General Practitioners (GPs), hospital doctors and nurses should be trained to understand the psychological dimension of living with long- term health conditions and skilled in exploring how people are coping with their diagnosis and adjusting to the impact it is having on their life, and the lives of their family and/or carers. At a minimum, GPs and hospital doctors should from the first point of diagnosis have a structured conversation with patients about their emotional wellbeing as part of their regular health check.

RECOMMENDATIONS

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More broadly, we need to adopt a ‘making every contact count’78 approach by moving to a culture of holistic care for both body and mind, in which all health and social care service interactions should be seen as opportunities to assess and address stressors that have a direct bearing on the mental health and wellbeing of patients and their families, and the treatment outcomes for the patient.

People presenting to a ‘first point of contact’ service in distress should receive a compassionate and trauma informed response regardless of where they live in the country. Rationale: Within our Stress Survey 16% of adults who felt stress at some point in their lives reported that they that have ‘intentionally hurt themselves’ due to stress and 32% told us that they have experienced suicidal thoughts. Suicide and self-harm strategies, and their local action plans, are at various stages across the UK. This means that there is also a variation in the comprehensiveness of these plans and levels of understanding around distress. The high number of people telling us that they felt so stressed that it had led to them considering suicide indicates that we need consistent and appropriate responses for everyone, and a compassionate approach from all first point of contact services. It has been recognised in Suicide Prevention Strategies that upskilling GPs in Suicide awareness and safety planning is crucial. This needs to include recognising different manifestations of distress and the impact of stress across one’s life. For young people the growing rates of self-harm need services to respond appropriately not only to the injury but to the underlying distress within an environment that minimises stigma and does not add to the stress of the young person.

The implementation of suicide and self-harm strategies across the UK will require a multi-agency approach in local planning processes, as people reach out in different ways. Some will use a GP as their first point of contact service and others will feel so overwhelmed that they seek help through an emergency route such as the ambulance service or Emergency Departments. Agencies (health, social care, education, benefits, prisons, housing) must ensure they

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provide clear pathways that enable people to get help when they are in distress, whether this is related to social stressors or a mental health crisis. This should involve the Voluntary and Community sector services available in their areas ensuring a first-time compassionate response to the different forms of distress that they may encounter.

Government and the Health and Safety Executive must ensure that employers treat physical and psychological hazards in the workplace equally and help employers recognise and address psychological hazards in the workplace under existing legislation.Health and safety at work legislation clearly requires employers to identify and mitigate physical and psychological hazards to workers (Management of Health and Safety at Work Regulations 1999). There are very few workplaces left in the UK in which employees working with hazardous chemicals would not be provided with protective equipment, and failures resulting in injury or even death prosecuted. We do not currently adopt the same attitudes and behaviours towards psychological hazards. A psychological hazard is any hazard that affects the mental well-being or mental health of the worker by overwhelming individual coping mechanisms and impacting the worker's ability to work in a healthy and safe manner (link below). We are calling for stronger action by government and relevant agencies including HSE to help employers recognise and address psychological hazards. We must also see also an increase in enforcement of breaches, and the development of appropriate case law and precedents to enable staff to use in practice the rights they have in law to be protected from harm.

http://www.hse.gov.uk/research/crr_pdf/2001/crr01356.pdf

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Governments across the UK should introduce a minimum of two ‘mental health days’ for every public sector worker. Our nurses, doctors, police officers and school staff are under immense pressure due to cuts across the public sector. According to the Office for National Statistics, stress and other mental health problems are the fourth most common reason for work sickness absence – but we know from our research that this is severely under-reported: 45% of people will make up an alternative reason for work absence rather than report a mental health issue to their employer.79 That’s why we are calling for “mental health days” to be rolled out across the public sector. Introducing and incentivising the use of mental health days could help to prevent stress escalating and turning into longer-term sickness absence by encouraging self-care. Private and third sector workers also experience stress, and we would like to see the practice of “mental health days” picked up more broadly, however, reducing the stress of the public sector workforce will benefit us all and we know that the UK government has committed to leading on workplace wellbeing in the public sector, as part of its response to the Thriving at Work.80 We believe that this is a tangible step that can be taken to increase and support mutual learning and sharing of good practice between public and private and third sector employers.

Mental health literacy should be a core competency in teacher training. This should be combined with rolling out mental health literacy support for pupils in schools across the UK to embed a “Whole School Approach” to mental health and wellbeing. We need to take action to reduce the stress that we can see emerging for the next generation. A half of mental health problems are established by the age of 14, however, teachers still receive very little training in child development, including the changes in brain development that affect them in their teenage years. Further, teachers also lack the right

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training and resources to understand, explore and promote resilience and mental health in our classrooms. Learning about mental health should be considered as important as learning about literacy and numeracy. All schools should strive to deliver a “whole school approach” to mental health, so that young people understand, and feel supported and comfortable discussing emotional issues, including exam pressures and relationships. It is alarming that 70% of children and young people who experience a mental health problem do not receive appropriate interventions at a sufficiently early stage. Embedding mental health literacy early on can help prevent problems arising in teenage years and into adulthood. Colleges and Universities must also take action to ensure that mental health literacy and well-being is embedded in the culture and ethos.

The UK Government should conduct an impact assessment of Welfare Reform and austerity programmes on mental health

Research has found that poverty is on the rise in the UK.81 This 2017 report highlights that the reduction in state support such as benefits and working tax credits (as well as rising rents and reduced home ownership) and the squeeze on living standards are contributing factors to the rise in poverty. Our survey findings suggest that these things are also likely to be causing people significant stress: 22% of people reported not having enough money to meet their basic needs and 21% feel stressed about debt. This was more marked in C2DE adults (non-working adults or those working in skilled, semi-skilled, or unskilled occupations), 29% of whom reported not having enough money to meet basic needs as a source of stress, as compared to 17% of ABC1 adults (those working in supervisory, managerial, administrative or professional occupations).

More broadly, all governments in the UK should conduct mental health impact assessments of all new financial policies to mitigate against any potential negative effects on mental health.

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More research is needed on the prevalence of stress in the population, and on how the experience of stress can be reduced at the community and societal level.

To our knowledge, there are currently no academic prevalence studies on how many people are experiencing chronic or long term stress at any one time. Our survey has identified that it is a significant issue for a large number of people, across many aspects of their lives, affecting mental health, physical health, and how they interact with others. We suggest that this merits a greater research and policy focus, that should be rooted in a regular systematic prevalence study. This would contribute to our knowledge of the factors affecting people’s mental health and contribute to our understanding of where to focus our prevention efforts.

In relation to research on reducing stress, the literature focuses predominantly on how individuals can cope, and on how to tackle stress in the workplace; there are comparatively few studies on how stress can be reduced at community and societal levels. This is an area requiring further research, as many of the stressors people experience, such as job insecurity, long-term health conditions, poverty and discrimination, are beyond their direct control. This research should form part of the governments Grand Challenge in England and be embedded in similar strategic approaches across the UK nations to create a holistic and prevention focused mental health research programme that aims to significantly reduce the prevalence of mental health problems across the next 20 years.

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Mental Health Foundation - RESEARCH REPORT · and enduring mental health problems stress can precipitate symptoms and potentially result in relapse. For example, stressful life events